Member Rights
To obtain information regarding the number of grievances, appeals and exceptions filed with the plan, please contact customer service.
Important Forms
Download forms by clicking the links below to open a form, and then either print or save it to your computer.
Member Appeal Form - Download and fill out this form to appeal a Plan denial (organizational determination) regarding your care.
Exceptions and Prior Authorization Form - To request a non-formulary drug or to obtain a medication prior authorization please download and fill out this form.
Exceptions and Prior Authorization Form - To request an Exception to our coverage rules please download and fill out this form.
Authorized Representative Form - Download and fill out this form to appoint another individual to file an appeal on your behalf.
Once you've filled out a form you can send it to PO Box 2777, Salem, OR 97308
or by fax to 503-371-8046. You may also call Customer Service for assistance
in filling out any of these forms.
For a summary of a specific topic please click the link below or simply scroll down the page:
- Appeals Process
- Grievance Process
- Appointing an Authorized Representative
- Prescription Drug Plan Policies
- Exceptions Process
Appeals Process
Physicians Choice Advantage + Rx provides all members with a meaningful process to appeal any Plan denial (referred to as an Organizational Determination) regarding the benefits a member is entitled to receive under Physicians Choice Advantage + Rx Plan. If a service is denied, in whole or in part, the member will be notified in writing of their appeal rights and are entitled to appeal the Plan decision.
All complaints regarding organizational determinations, in whole or in part will be processed according to the procedures listed below:
All appeals must be filed within 60 days of the organizational determination letter. The request may be done verbally or a request may be made when the member submits the request for an appeal including all relevant information in writing. If the member is submitting the appeal in writing the timelines will begin once that is received.
If the Plan receives an oral request it will be recorded in the member's own words and repeated back for confirmation and acknowledged by the member in writing.
Within 5 days of receiving the appeal request, the Grievance and Appeals Administrator will send a confirmation letter indicating that the appeal has been entered into the appeal process and will provide information about the process to the member.
The member will be given the opportunity to present any additional information related to the issue, in person or in writing.
If at anytime during this process the member wishes to withdraw the appeal request he/she may do so by filing a written request to the Plan, the Social Security Administration or the Railroad Retirement Board. If this information is given verbally to the Plan a confirmation letter will be sent to the member to document the request for cancellation.
Once the file is prepared, the Grievance and Appeals Administrator will forward the completed file and any additional information and supporting documentation to Medical Review. A person or persons who were not involved in making the initial organizational determination will review the completed file.
All decisions must be made as expeditiously as the member's health requires or not to exceed 30 days from the original receipt date of the appeal.
If a decision can not be made within 30 days from receipt of the appeal, the Plan may extend the time frame an additional 14 days, provided the member may benefit from the extension and is notified of the Plan's intent. The member may file a grievance if not satisfied with the extension.
Favorable Decision: Original Denial overturned - the member will be notified of the outcome no later than 30 days from the receipt of the original appeal request (or 44 days if a 14 day extension is taken).
Non-Favorable Decision: Original denial upheld - if the denial is upheld in whole or in part, the member will be notified in writing of the upheld denial and informed that the member appeal will be forwarded to MAXIMUS Federal Services. The entire file will be forwarded, including all information that was used to make the determination to MAXIMUS Federal Services at the same time the member is being notified.
Back to top.Grievance Process
If you are not satisfied with the services Physicians Choice Advantage + Rx provides, you can report a complaint or grievance. If the complaint is verbal and not resolved to your satisfaction at the customer service level; or if the grievance is in writing; or if the complaint does not involve a Plan Organizational Determination, the Grievance and Appeals Administrator will process the grievance as outlined below:
The Grievance and Appeals Administrator will receive and document the grievance and enter the information in the Grievance and Appeals database specifically designed to track the grievance for timeliness and categorize the type of grievance for Quality of Care reviews.
The grievance will be acknowledged within 5 days of receipt with written notification to the member.
Member will be given the opportunity to present any other information related to the issue either in person or in writing.
The member may also file a complaint or grievance through the QIO process and the Plan will respond to all requests as appropriate.
The appropriate department or facility will be notified of the complaint and all information regarding the grievance will be gathered and documented by the Grievance and Appeals Administrator. All grievances will be reviewed in accordance with the facts presented and will be handled on a case by case basis.
Written resolution will be sent to the member as appropriate (within 30 days of receipt of the original grievance). The written notice will restate the grievance in its entirety and all points will be addressed.
Quality of Care concerns will be forwarded to the Quality Improvement Coordinator for further action if necessary.
All grievances will be carefully monitored on a quarterly basis for any trends in the quality or delivery of health care services.
Grievances will be carefully recorded for full reporting to CMS and to any member or potential member upon request.
Verbal Grievances may be submitted orally by calling: 503-587-5157 or 1-866-864-5566.
Written Grievances may be mailed to Physicians Choice Advantage, PO Box 2777, Salem, OR 97308 or faxed to 503-371-8046.
Back to top.Appointing an Authorized Representative
As a Physicians Choice Advantage + Rx beneficiary, you have the right to appoint another individual (such as a relative, advocate, friend, attorney or any physician) to act as your representative and file an appeal on your behalf. A separate Authorized Representative Form must be filled out for each separate appeal.
By appointing a representative to act on your behalf concerning your appeal, you are giving him or her the right to:
- Obtain information about your claim to the extent consistent with Federal and State laws;
- Submit evidence;
- Make statements of fact and law; and
- Make any request, or give and receive notice about the appeals proceedings.
To appoint a representative both you and the representative you have assigned must sign, date and complete an Authorized Representative Form. This form may be mailed to PO Box 2777, Salem, OR 97308 or faxed to 503-371-8046. Once the form is received by Physicians Choice Advantage + Rx it is considered current for one year. The same Appeals Process applies to any appeal submitted by you or your appointed representative. After one year has passed, you must complete a new form if you would like to continue the appointment of that representative.
Back to top.Medication Management Policies
Some covered Medicare Part D drugs may have additional requirements or limits on coverage. These requirements and limits may include:
- Prior Authorization: Physicians Choice Advantage + Rx requires you to get prior authorization for certain drugs. (You may need prior authorization for drugs that are on the formulary or drugs that are not on the formulary and were approved for coverage through our exceptions process.) This means that you will need to get approval from Physicians Choice Advantage + Rx before you fill your prescriptions. If you don't get approval, Physicians Choice Advantage + Rx may not cover the drug.
- Step Therapy: In some cases, Physicians Choice Advantage + Rx requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Physicians Choice Advantage + Rx may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Physicians Choice Advantage + Rx will then cover Drug B.
- Quantity Limits: Physicians Choice Advantage + Rx is interested in your health and safety. In some cases due to drug interactions, FDA requirements or the condition your specific drug treats, Physicians Choice Advantage + Rx may place a limit on either the number of days supply or the quantity of certain drugs.
You can find out if your drug has any additional requirements or limits by looking in the Formulary (the list of covered drugs begins on page 7).
Back to top.Exception Process
You can ask Physicians Choice Advantage + Rx to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.
- You can ask us to cover your drug even if it is not on our Formulary.
- You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Physicians Choice Advantage + Rx limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.
- You can ask us to provide a higher level of coverage for your drug. For example, if your drug is usually considered a brand name drug, you can ask us to cover it as a generic instead. This would lower the amount you must pay for your drug.
Please note, if we grant your request to cover a drug that is not on our Formulary, you may not ask us to provide a higher level of coverage for the drug. Generally, Physicians Choice Advantage + Rx will only approve your request for an exception if the alternative drugs are included on the plan's Formulary, the low-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
To request an Exception to our coverage rules please download and fill out the Exceptions and Prior Authorization Form and mail to PO Box 2777, Salem, OR 97308 or by fax to 503-371-8046. You may also call Customer Service for assistance in this process.